Artificial fever therapy of gonorrheal arthritis

ARTIFICIAL FEVER THERAPY GONORRHEAL ARTHRITIS REPORT H.

OF THIRTY/ONE

WORLEY

OF

CASES*

KENDELL, M.D.

Assistant Director, Department of Fever Therapy Research WALTER

W.

WEBB,

M.D.

Resident Physician in Medicine AND WALTER

M.

SIMPSON, M.D.?

Director of Diagnostic Laboratories and Department of Fever Therapy Research Miami VaIIey HospitnI DAYTON, OHIO

0

NE of the most frequent and disabIing compIications of gonorrhea is gonorrhea1 arthritis. In a high proportion of cases permanent deformity and disabiIity, affecting one or severa joints, is the end resuIt. The fact that so many different methods of treatment have been empIoyed provides evidence of the inadequacy of most or a11 of them. During the past three years, the outIook for patients with gonorrhea1 arthritis has been enormousIy improved. In March, 1932, a thirty-nine year oId man was referred to us for artificia1 fever therapy because of resistant seropositive syphihs. The history and physica examination revealed that the patient aIso had active chronic gonorrhea1 arthritis of five months’ duration, involving intraceIIuIar the right wrist. Gram-negative dipIococci were found in Iarge numbers in urethra1 smears. After the third artificia1 fever treatment, each of which consisted of five hours of fever above 103"~. (40.6”c.) at intervals of one week, a11 evidence of active gonorrhea1 arthritis had disappeared. The joint function, which had been practicaIIy nil, was restored to

go per cent of normaI. The urethraI smears became negative for gonococci after the fourth treatment and have remained negative since that time. Encouraged by this coincidenta observation we decided to treat other cases of gonorrhea1 arthritis. We have now compIeted the course of fever therapy of 3 I patients with gonorrhea1 arthritis. Scattered reportsl-g of simiIar favorabIe experiences with artificial fever therapy by physica methods have appeared in medica Iiterature since 1932. The resuIts obtained with a variety of physica modaIities have been summarized and tabuIated in a recent communication by Hench, SIocumb and Popp.1° Of 33 cases mentioned in the 9 reports reviewed by these authors, data on the resuIts obtained in the treatment of 24 patients couId be caIcuIated. Of these 24 patients, 22 (92 per cent) were “compIeteIy reIieved”or “cured.” FaiIure resulted in only 2 cases (8 per cent) and was attributed to inadequate fever production. Hench, SIocumb and Popp have treated

* This investigation was made possibIe by a grant from the CharIes F. Kettering Foundation. t With the collaboration of CharIes F. Kettering, x.D., Fred K. KisIig, M.D.(deceased), Edwin C. SittIer, B.S. in Engineering, L. G. Kauffman, M.D., Jerome K. Hartman, M.D., Eunice Fraizer, M.A., FIorence Storck, R.N., Mary Louise WoIff, R.N., Ruth Walter, R.N. and Florence Buroker. R.N. 428

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SERIES VOL. XXIX,

No. 3

KendeIl

et al.- -Fever

16 patients suffering from gonorrhea1 arthritis with artificia1 fever therapy, utiIizing the Kettering hypertherm. Nine of the patients had acute arthritis, whiIe 7 had the disease in a chronic form. Eighty-eight per cent of the patients with acute gonorrhea1 arthritis were promptIy “cured,” or 12 per practicaIIy so, whiIe the remaining cent obtained marked improvement. Of the - patients with chronic gonorrhea1 arthritis, a11 but one were markedIy improved. The authors state: “In gonorrhea1 arthritis, resuIts are so striking and apparently so superior to those obtained by other methods, that we can prescribe fever therapy as the method of choice with considerabIe assurance.”

Therapy

American Journ:rl of’ Surpery

429

cabinet in which the nude patient Iies, with his head extending outside the cabinet. Sponge-rubber insuIation is utilized in the

APPARATUS

At the beginning of this undertaking, several physica modaIities were empIoyed, incIuding hot baths, cabinets heated with carbon-filament eIectric Iamps, electric bIankets, diathermy and radiothermy. The cIinica1 results obtained with any of these methods were essentiaIIy simiIar, when the fever couId be maintained at a suff%ientIy high IeveI for a suffIcientIy Iong interva1. The recognition of the fact that some of these methods possessed inherent hazards prompted us to attempt the deveIopment of a reIativeIy safe and simpIe method for fever induction and maintenance. The apparatus now used for fever induction and maintenance is an air-conditioned cabinet deveIoped at the Miami VaIIey Hospital and at the Research Laboratories of the Frigidaire Division of the Genera1 Motors Corporation, Dayton, with the coIIaboration of Mr. Charles F. Kettering and Mr. Edwin C. SittIer. The name “ Kettering hypertherm ” has been appIied to the apparatus. In the present stage of its development, the Kettering hypertherm” (Fig. I) consists of an insulated ’ Fifty-five ofthesc units have been lent to 20 medical research centers, strictIy for investigative purposes. The ph?-sicians and nurses charged with this undertaking reccivcd special training in the Department of Fever Therapy Research at the Rliami Valley Hospital

Fro.

I.

Kettering

hypertherm.

neck region to permit the patient to shift his position. The patient Iies on a comfortabIe air mattress, supported by a box-like bed, which is roIIed in and out of the cabinet at wiI1. In the rear of the cabinet is a smaI1 insuIated fire-proof compartment in which the air-conditioning apparatus is housed. The dry-buIb air temperature is controIIed by a thermostat. The wet-buIb temperature, which governs the percentage of reIative humidity, is controIIed t,>- a humidistat or by a wet-bulb thermostat. Th e air-veIocq ’ ’ within the cabinet is

before the apparatus was released. A simpler, smaller and less costly apparatus is now being drvelopecl. It is probahh that this apparatus will ultimately be avaiIabIe to certain qualified institutions. Adequate preIiminary training of physician- and nurse-personnel is an essential requirement for this type of work. Artificial fever therapy should be restricted to qualified institutions. Otherwise, this method of therapy is aImost certainly doomed to a period of discredit, not unlike that which folIowed the introduction of roentgen rays. The production of artificia1 fever at a high tcmperature IcvcI is not adnptabh to cndinary oIIice practice.

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42.2~ 41.7c._ 41.1 c._ 40.6c._ 4o.oc._ 39.4c._ 38.9c._ 38.3c._ 3mc._ 3ZZc._ i 36.7c._ 36./c._ 356c._ 35oc._ 34.4c._ 339c._ 33.3c. 32.8~. 0 32.2~. 0

I/RLLEY,

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T/ME INTERV/~L - MINUTES 30 60 30 60 30 60 30 60 30 60 30 60 30 60 I-HOUR Z-HOUR 3-HOUR 4-HOUR 5MUR 6-MOUR FHOUR

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FIG. 2. Thermometric gradient study in a patient with gonorrhea and gonorrhea1 arthritis of a knee joint. Recta1 temperature was determined with a certilied mercury thermometer at intervals of approximately fifteen minutes for nine hours. Temperatures of knee joint, anterior urethra and posterior urethra were determined with thermocouples at intervaIs of five minutes. Recta1 temperature was elevated to 105.6’~. in one hour. Temperatures of various tissues reached practicaIIy same Ievel as recta1 temperature during maintenance period, with exception of temperature of anterior urethra which was slightly higher during induction and maintenance period, and exhibited fluctuations whenever skin surface of patient was cooIed. ThermocoupIe temperatures were not recorded until twenty-live minutes after treatment was begun, due to mechanical difLcuIties. When recta1 temperature had dropped to IOO.~'F., posterior urethra temperature had dropped to g5.s”F.; knee joint temperature had dropped to 93.4’F.; and anterior urethra temperature had dropped to 92.8OF.

JO8 c: 107 E 106 c: 105 R to4 F: wp 103 c: E IO2 c: & I01 E 5 100 F: $ 99 f: fJ 98 5 8 97~ 2, 96E g 95F: 13 94k ii! 93E 92 F. 91 c: 90~

Ytu

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VOL. XXIX.

No. 3

KendeII

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controIIed by bIowers of fixed speed. DrybuIb and wet-buIb temperatures within the cabinet are indicated on Iarge diaIs, equipped with warning pilot Iights, on the top of the front end of the cabinet, where they may be constantIy observed by the nurse-technician. The temperature-humidity factors may be controIIed by the turning of a single knob. The average set of air conditions to which the patient’s body is subjected is: dry-buIb air temperature of I~o’--150’~. (60”-65”c.), relative humidity of of 35-40 per cent, and air veIocity 423 cubic feet per minute. The elevation of the recta1 temperature to IOS’F. (40.6’~) is ordinariIy accompIished in forty minutes to one hour. The air is constantIy conditioned b.y. continuous passage through the air-condrtroning compartment. The safety and comfort of the patient are greatIy enhanced bv the accurate controI of the relative humiditv. The mechanism of fever induction with the Kettering hypertherm depends primarily upon heat transfer by conduction from the circulating heated air and the heated air-mattress. This factor, combined with prevention of the norma rate of heat loss from the body by radiation and evaporation, is responsibIe for the eIevation of the body temperature and its maintenance at any desired IeveI. The simplification of the apparatus, the removai of hazards inherent in certain other physica modalities, and the suppIying of Iarge quantities (2-4 Iiters) of sodium chIoride soIution (0.6 per cent) by mouth during the treatment to repIace chIoride loss”,” have converted this form of therapy from one requiring hospitaIization to one in which the patient is usuaIIy abIe to return to his work on the day foIIowing treatment, unIess the extent of his disabiIity makes hospitaIization desirabIe. We have found that hospitalization for approximately two weeks is a distinct advantage in the management of acute gonorrhea1 arthritis. The need for hospitaIization is usuaIIy not so urgent in cases of chronic gonorrhea1 arthritis.

Therapy

THERMOLABILITY

American

OF

Journal

THE

of Surgery

43’

GONOCOCCUS

It has Iong been known that Neisseria gonorrheae is a particuIarIy thermoIabiIe There are many records of organism. spontaneous recovery or remission from the manifestations of gonococcal infections during intercurrent febriIe disease. It is aIso we11 known that the gonococcus soon disappears and is repIaced by. secondary invaders when it reaches deep tissues, such as the faIIopian tubes. Neisser and SchoItzl” found it diffIcuIt to cuItivate the gonococcus in patients with fever. The organism does not grow we11 on artificia1 mediums at temperatures above I 00.4’~. ($3°c. j. The recognition that fever exerts a favorabIe influence upon gonorrhea and its complications has Ied to treatment with fever produced by maIaria inocuIation or with chemica1 or foreign protein substances. WhiIe some satisfactory cIinica1 resuIts have been obtained by such methods, they have the drawback of being inconstant in their fever-producing properties and frequently provoke serious, uncontroIlabIe, and occasionaIIy fatal, reactions. Localized fever treatments have been carried out, for the most part with high-frequency eIectrica1 currents such as diathermy or radiothermy. The chief objection to this procedure is that the heat treatment is Iimited to a IocaIized area. Patients with gonorrhea1 arthritis are suffering from a systemic disease, requiring systemic treatment. The indefinite, and often contradictory, reports of the therma death time of Neisseria gonorrheae have been cIarified 63 the extensive thermal death time gradient studies made recently by Carpenter, Boak, Mucci and Warren.13 When it became apparent that gonococca1 infections responded to artificia1 fever therapy when the fever was sustained for long periods at a high Ievel, these workers set out to determine the therma death time gradient of the gonococcus when subjected to temperatures that can be toIerated by man. The in vitro therma death time of I 3 strains of Neisseria gonorrheae was determined at different

432

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temperature IeveIs. Some of the strains had been under artificial cuItivation for many years, whiIe others had been isoIated one to four months previously. At 102.2’~. (39”c.) growth was not appreciabIy affected. At 104’F. (~o’c.), about 99.7 per cent of the organisms were kiIIed by ten hours’ exposure. At 105.8’~. (~I’c.), 99 per cent of the gonococci were destroyed in from four to five hours’ exposure; the remaining I per cent required eIeven to twenty-three hours. At 106.7~~. (41.5Oc.) and 107.6~~. (42”c.), 99 per cent of the gonococci were rendered non-viabIe in two hours, whiIe the remaining I per cent required five to twenty hours. The cuItures which had been under cuItivation for onIy a short period were most susceptibIe to heat. From these studies it became apparent that it wouId be possible, in most instances, to exceed the therma death time of the organism without injury to the human host, by adapting the temperature IeveI in patients with gonococca1 infections to the therma death time of the organism. We have repeated the experiments of Carpenter, Boak, Mucci and Warren with essentiaIIy identica1 resuIts. METHOD OF TREATMENT During the past four years we have subjected 383 patients to 2844 artificiaI fever treatments (approximateIy I 6,000 hours of sustained fever). With the exception of occasiona miId skin burns, which occurred particuIarIy at the beginning of this undertaking, no person has been injured by the treatments. Of these, 65 patients suffering from simpIe gonococca1 urethritis or from gonococca1 urethritis compIicated by cervicitis, saIpingitis, ophthaImia or arthritis, have been treated. This report is concerned onIy with the 31 patients who had gonorrhea1 arthritis. The favorable resuIts obtained in the other manifestations of gonococca1 infection wiI1 be made the subject of a subsequent report. Suffice it to say that the resuIts are practicaIIy identical with those

Therapy

SEPTEMBER, rgsg

obtained by Desjardins, Stuhler and Popp, l4 of the Mayo CIinic, which moved StuhIer15 to state in a Iater report: “ I beIieve that the introduction of fever therapy for gonococcal infections is one of the greatest advances made in the last fifty years. I beIieve it is of even greater importance to the cIinician than was the discovery of the gonococcus by Neisser in 1879.” WhiIe it wouId seem IogicaI to adapt the treatment of each patient to the therma death time of the strain of gonococcus producing his disease, there are important objections to such a pIan. It requires severa days to carry out accurate therma death time determinations. OccasionaIIy the organism is recovered with dificulty. IndividuaI patients may harbor several strains, which differ in their heat-resistance. In rare instances, highIy resistant strains require twenty or more hours at temperatures of 107’~. (41.7’c.) or above before they are destroyed. Moreover, it is quite IikeIy that factors other than direct destruction of the gonococcus, such as stimuIus to the defense mechanisms of the body, are responsibIe in part for the resuIts achieved by fever therapy. For practica1 purposes, we have found that four or five treatments, each of five to seven hours’ duration, at a temperature range of 106’~. (41’c.) to 106.8~~. (41.5”c.), at intervaIs of three to five days, are productive of prompt and satisfactory resuIts. EarIy in the course of this undertaking, it was our practice to give the treatments at intervaIs of one week or Ionger. The average number of treatments given to the patients in this series was approximateIy 5 (4.8). The average interva1 between treatments was approximateIy seven (7.4) days. Experience has taught us that fewer treatments are required if the interva1 between treatments is shortened. Four treatments at intervaIs of three to five days, the interva1 depending upon the genera1 condition of the patient and his toIerance of the treatments, are usuaIIy regarded as a minima1 course. If a11 evidence of activity in either the joints or the urethra

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has not disappeared, are given. CLINICOPATHOLOGIC

KendeII additiona

et aI.-Fever

treatments

OBSERVATIONS

IncIuded in the series which forms the subject of this report were 26 men and 5 women. The ages ranged from sixteen to forty-five years; the average was twentysix years. Nineteen were suffering from the acute form of the disease, while 12 had chronic gonorrhea1 arthritis. The patients were not seIected. The onIy requirements were that a diagnosis of gonorrhea1 arthritis couId be estabhshed and that the physica condition of the patient wouId permit him to toIerate the treatments. AI1 patients are subjected to a thorough diagnostic survey to determine eIigibiIity for fever therapy. SpeciaI studies are made of cardiac, vascuIar and renaI functions, in&ding eIectrocardiographic, basa1 bIood pressure and brood chemical analyses. Contrary to common beIief, muItipIe joints were usuaIIy affected. In 23 of the patients (74 per cent) the arthritis was poIyarticuIar. In the 8 patients with monarticular arthritis the knee was invoIved in 4 instances; the ankIe in 2; the wrist in I; and the foot in I. In the poIyarticular group one ankIe was involved in I I instances; both ankIes in 5; one knee in 7; both knees in 2; one foot in 4; both feet in 4; one hand in 2; both hands in 6; one hip in 2; both hips in 5 ; one wrist in 5 ; both wrists in 2; one shouIder in 4; both shouIders in 2; one eIbow in 3; cervica1 spine in 2; and sternum in I. Even though there was no great difference in the ultimate response of the different joints to fever therapy, the weight-bearing joints were often much sIower in returning to normaI function. During the routine preIiminary diagnostic survey, diagnostic aspiration of the affected joints was done to determine the presence or absence of fluid. Pyarthrosis was found to exist in one or more of the affected joints of 8 patients. Gonococci were recovered by cuIture of the aspirated exudate from the knee joints of 2 patients

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with monarticuIsr arthritis. An effort was made to determine the total white cell count and differentia1 count on a11 aspirated specimens. Due to the abundance of fibrin in the aspirated fluid of a few of the patients accurate determinations couId not aIways be made. The total Ieucoc!;te count and poI\-morphonuclear neutrophrIe count was much higher in the s>-no\iaI fluid infected with the gonococcus. There was no appreciabIe difference in the total protein content in infected and non-infected joint ffuids. Twenty-one of the 31 patients had received some form of local chemical treatment of the genitourinary tract before the onset of arthritis. The treatment consisted of the instillation of some silver preparation into the urethra. Some of the patients with chronic urinary tract infection had received prostatic massage and treatment with sounds. A few of the patients attributed the onset of the arthritis to IocaI traumatism or to some unusua1 exertion, such as lifting heavy objects. There was no evidence that these factors were of any importance in the onset of the disease. In a11 of the 31 cases a definite history of previous gonococcaI infection of the genitourinary tract couId be elicited. At the time of the diagnostic survey prior to fever therapy the smears of 23 patients revealed the presence of gram-negative intraceIIuIar dipIococci. Of the 8 patients with negative smears, 3 had acute gonorrhea1 arthritis and 5 had chronic arthritis. Of the 3 patients with acute arthritis, but negative smears, there were 2 men with acute prostatitis and one woman with acute cervicitis; a11 were reported to have had positive smears previous to Their admission to the Fever Therapy Research Department. Of the 5 cases of chronic arthritis, with negative smears, a11 had had positive smears whiIe under the observation of their phvsicians. In no case was the infection restiicted to the anterior urethra in the male. Of the 5 female patients, there were 2 with pelvic ceIIuIitis, 2 with acute cervicitis, and one with urethritis compIicated by Rnrtholinian

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abscess. FoIIowing the course of fever therapy the smears from the genitourinarv tract of 24 patients showed no gonococci. The smears of 7 patients were stiII positive. Of these 7 patients, the smears of 4 became negative within 2 weeks without further treatment; 3 patients received IocaI chemicaI treatment foIIowing the fever treatments. Two of the 3 patients receiving additiona IocaI treatment had received inadequate fever therapy; the third had received what was regarded as sufficient fever therapy, but the urethra1 smears stiI1 remained positive. This patient had severe foIIicuIitis and posterior urethra1 stricture. After prostatic massages and the introduction of sounds, the smears became negative. In a11 of the maIe patients prostatic massage was carried out at weekIy intervaIs until pus ceIIs and shreds did not appear in the urine. The average number of prostatic massages was 4. CompIete genitourinary examinations were made on a11 patients at weekIy intervaIs, in&ding compIete urine anaIysis and the two-gIass urine test. Urethral sounds were passed and endoscopic examination was done in a11 cases before dismissaL Successive reexaminations have reveaIed no recurrence of gonorrhea in any of the patients. The erythrocyte sedimentation time was determined routineIy before fever therapy was instituted, at the compIetion of the course of fever therapy, and usuaIIy at intervaIs of two weeks unti1 it returned to approximateIy the normaI IeveI. The Linsenmeyer method was empIoyed, in which sedimentation time of three hours or more is regarded as normaI. In the case of acute gonorrhea1 arthritis the average sedimentation time before fever therapy was twentyone minutes; in the chronic cases, one hour and seventeen minutes. At the compIetion of the course of fever therapy the average sedimentation time for the acute cases was one hour and eIeven minutes; in the chronic cases, one hour and forty minutes. The average interva1 for the return of the sedimentation time to norma was one month and nine days in the cases with

Therapy

SEPTEMBER, 1935

acute gonorrhea1 arthritis. In the chronic cases, the average interva1 for the return of the sedimentation time to the normal IeveI was one month and fourteen days. It wiII be observed that there is no essentia1 difference in the time required for the sedimentation time to return to the normaI IeveI in patients with either acute or chronic gonorrhea1 arthritis. The sedimentation time of untreated patients with acute gonorrhea1 arthritis is distinctIy shorter than in patients with the chronic form of the disease. WhiIe the sedimentation time is of no vaIue as a diagnostic procedure, it provides a reIiabIe guide to the response to therapy. The average intervaI between the onset of gonorrhea and the onset of arthritis was one month and fourteen days in the acute cases, and two months and two days in the chronic cases. In one exceptiona case there was a three-year interva1 between the initiaI infection and the first onset of the arthritis; this patient had experienced three recurrent attacks of gonorrhea1 arthritis and four recurrent attacks of gonorrhea, the last of which recurred four and one-haIf months prior to the institution of fever therapy. The average interva1 between the onset of arthritis and the institution of fever therapy was eIeven days in the acute cases, and two years and three months in the chronic cases. In g of the 12 chronic cases the average interva1 was four months and nine days; the other 3 patients had had previous attacks of gonorrhea1 arthritis extending over periods from four to thirteen years. Of the Ig patients with acute gonorrhea1 the average improvement in arthritis, joint function immediateIy after the concIusion of the course of fever therapy was 77.6 per cent; in 3 patients the restoration of joint function was complete. Of the 12 patients with chronic gonorrhea1 arthritis, the average improvement in joint function at the concIusion of the course of fever therapy was 62.5 per cent; in 4 patients joint function was compIeteIy re-

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stored. At the present time, the average improvement in joint function in the acute cases is 98.4 per cent; 13 patients have obtained compIete restoration of joint function. In the chronic cases, the average improvement at the present time is 88.3 per cent; one additiona patient has obtained complete restoration of joint function. Worthy of particuIar mention are our experiences with 2 cases of chronic gonorrhea1 arthritis, in which aImost compIete Iimitation of motion of one knee joint remained after the usual course of fever therapy. After a11 evidence of active inff ammation had disappeared the joints were manipmated under genera1 anesthesia (brisement force) in order to separate the Fever therapy was fibrous adhesions. immediatelyinstituted folIowing the surIn both cases pracgical manipulation. ticaIIy compIete joint function has been restored. Orthopedic management is a requirement in those cases of chronic gonorrhea1 arthritis in which partia1 ankyIosis has occurred prior to the institution of fever therapy. SUMMARY

AND

CONCLUSIONS

I. High, sustained, controIIed artificia1 fevTer is the treatment of choice for gonorrhea1 arthritis. 2. Gonorrhea1 arthritis is a manifestation of a systemic disease, requiring svstemic treatment. In vitro therma death time studies, and the cIinica1 response of patients with gonococca1 infections to artificia1 fever therapy, indicate that it is possibIe, in most instances, to destroy gonococci in the various Iesions of the disease with high, sustained body temperature. In addition to this steriIizing effect, there is evidence that artifrcia1 fever therapy stimuIates immune reactions. 3. Thirty-one patients with gonorrhea1 arthritis, associated with gonococca1 infection of the genitourinary tract, have been treated by us with artificial fever therapy, utiIizing a simphhed, reIativeIy safe and controIIabIe air-conditioned apparatus,

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435

known as the Kettering hypertherm. Of rg patients with acute gonorrhea1 arthritis the average improvement in joint function immediateIy after the concIusion of the course of fever therapy was 77.6 per cent; in 3 patients the restoration of joint function was compIete. The uItimate average improvement in joint function in the cases of acute gonorrhea1 arthritis was 98.4 per cent; 13 patients have obtained compIete restoration of joint function. Of the 12 patients with chronic gonorrhea1 arthritis the average improv-ement in joint function at the concIusion of the course of fever therapy was 62.5 per cent; in 4, patients joint function was completely restored. The ultimate improv-ement in. joint function in the cases of chronic gonorrhea1 arthritis was 88.3 per cent. At the conclusion of the course of fever therapy gonococci had disappeared from the smears of the genitourinary tract of of -1 patients 24 patients. Th e smears became negative within two weeks after the last fever treatment. Supplemental treatment eJiminated a11 evidence of gonococcaJ infection of the genitourinary tract of the remaining 3 patients. 4. In 2 cases of chronic gonorrhea1 arthritis aImost compIete Iimitation of motion of one knee joint remained after the conclusion of the course of artificial fever therapy. Orthopedic manipulation (brisement force) under genera1 anesthesia was done to separate the fibrous adhesions. Artificial fever therapy was instituted immediateIy foIIowing the surgical manipmation. PracticaIIy normal joint function has been restored in both cases. REFERENCES I. CARPENTER, C. M., and WARREN, S. L. Artificially

induced fever in the treatment of disease. New York State J. Med., 23: 997-1001 (Sept. 1j, 1932. 2. BISHOP, F. W., HORTON, C. B., and WARREN, S. L. A cIinicaI study of artificia1 hyperthermia induced by high frequent currents. Am. J. M. .Sc., 184: 5’5-533 (Oct.), 1932. 3. TENNEY, C. F. ArtificiaI fever produced by the short wave radio and its therapeutic application. Ann. Int. Med., 6: 457-468 (Oct.), 1932. [For Remainder of References see page 452.J

4.52

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Wyker-Foreign

with 68 per cent poIymorphonucIear neutrophiles. Temperature IOO.~~F., puIse IOO and respirations 18 per minute. The patient was taken to the operating room and under ether anesthesia a median Iaparotomy was done. The position of the foreign bodies was ascertained and the sigmoid fIexure brought into the wound. AbdominaI pads were inserted and the adjacent intestines we11waIIed Off.

The sigmoid was then incised aIong its long axis and a Iarge, swollen, juicy Iemon 3 inches in its Iong diameter removed. A sponge forceps was then inserted through the opening in the sigmoid and passed into the rectum. The open top of a gIass jar was seized and with the aid of an assistant pressing from beIow with his fingers in the rectum, a 3 ounce opa1 gIass coId cream jar was removed through sigmoid. The patient Ieft the operating room in good condition. The first few days postoperative were a bit hectic. For three days he passed a smaI1 amount of bIoody urine which cIeared up.

REFERENCES

OF DRS.

M.

ArtificiaI

fever

therapy.

Eight days after operation, his temperature was normaI, and sixteen days after he was waIking about the ward. He was discharged twenty-two days after admission, cured. During convalescence he had time to think up a story. A few days before admission to the hospita1 he asked a drug cIerk what to do for a bad case of piIes (examination at hospita1 showed no hemorrhoids). He was told to apply coId cream and Iemon juice. He went home and took a rectanguIar jar fuI1 of cold cream, unscrewed the top and pIaced a Iemon in the mouth of the jar, and then pushed the jar and Iemon up his rectum.’ PoIice investigation reveaIed that this patient had been guiIty of attempted seduction with young girls. We assume, that this accident occurred therefore, during an act of sexua1 perversion. 1EDITOR’S NOTE: Here again as in the case reported by Dr. Kraker, in this type of case too much credence must not be pIaced in the patient’s history.

KENDELL,

4. WARREN, S. L., and WILSON, K. M. The treatment of gonococca1 infections by artificial (generaI) hyperthermia. Am. J. Obst. @ Gynec., 24: 592598 (Oct.), 1932. 5. BERRIS, J. M. The treatment of arthritis by artifrcia1 fever: Preliminary report of twenty cases. J. Michigan M. Sot., 32: 355-358 (June), 1933. 6. SIMPSON,W. M., KISLIG, F. K., and SITTLER, E. C. UItrahigh frequency pyretotherapy of neurosyphilis: A preIiminary report. Ann. Znt. Med., 7: 64-75 (JuIy), 1933. 7. ATSATT, R. F., and PATTERSON, L. E. The use of eIectropyrexia in gonorrhea1 arthritis. Pbysiotherapy Rev., 13: 144-146 (JuIy-Aug.), 1933. 8. KOVACS, R., and KOVACS, J. PhysicaI and constitutiona1 measures in chronic arthritis. Neu, York State J. Med., 33: I 148-r 154 (Oct. I), 1933. g. REIMANN, H. A. Significance of fever and blood protein changes in regard to defense against infection. Ann. Znt. Med., 6: 362-374 (Sept.), 1932. SIIMPSON, W.

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.%a$ Meet. Mayo Clin., 9: 567-571 (Sept. rg), 1934. HENCH, P. S., SLOCUMB, C. H., and POPP, W. C. Fever therapy: ResuIts for gonorrhea1 arthritis, chronic infectious (atrophic) arthritis, and other forms of “rheumatism.” J. A. M. A., 104: 17791790 (May 1% 1935. SIMPSON, W. M. Influence of radiotherm pyretotherapy on chIoride metaboIism. J. A. M. A., IOO: 67-68 (Jan. 7), 1933. NEISSER, A., and SCIIOLTZ, W. Gonorrhoe, in Handbuch der pathogenen Mikroorganismen. Jena, 1903, 3: 168. CARPENTER, C. M., BOAK, RUTH A., MUCCI, L. A., and WARREN, S. L. Studies on the physioIogic effects of fever temperatures. J. Lab. c~ Clin. Med., 18: 981-991 (JuIy), 1933. DESJARDINS, A. U., STUHLER, L. G., and POPP, W. C. Fever therapy for gonococcic infections. J. A. M. A., 104: 873-878 (March 16), 1935. STUHLER, L. G. Fever therapy of gonococcai infections. Proc. staff Meet. Mayo Clin., IO: 207-208 (March 27), 1935.

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